On 2015 Mar 24, Michelle Lin commented:

Video interview with first author, Dr. Rebecca Smith-Bindman (UCSF Department of Radiology), and co-author Dr. Ralph Wang (UCSF Department of Emergency Medicine) hosted at the Academic Life in Emergency Medicine website. In this video, questions and nuances in this landmark paper were addressed.

http://www.aliem.com/author-insight-ultrasonography-versus-ct-for-suspected-nephrolithiasis-nejm/

Four questions were posed:

• Q1: About 1/3 of patients in the ultrasound study arms eventually went on to get CT’s in the same ED stay. What would you recommend to clinicians about when that should be?

• Q2: Can you address generalizability issues in this 15-center study whereby the cohort has 40% with a history of previous kidney stones and only 60% demonstrating microscopic hematuria. Also what are your recommendations for obese patients (men >280 lb, women >250 lb) who were excluded from your study? CT them all?

• Q3: What has been the feedback from urologists since the paper was published? What are the drivers of CT ordering?

• Q4: What’s next? What’s NOT in your paper?

Ultimately, this paper advocates for bedside ultrasonography over CT as the first-line diagnostic modality for patients with suspected kidney stones. In this 15-center study, the ~1800 ultrasounded patients had good primary and secondary outcomes despite the fact that 2/3 did NOT undergo a CT in the first ED visit.

On 2014 Nov 02, Swapnil Hiremath commented:

This study was discussed on Oct 7th 2014 in the open online nephrology journal club, #NephJC, on twitter. Introductory comments are available at the NephJC website and cross-posted at the eAJKD blog. It was a great discussion, with more than 20 participants, including nephrologists, urologists and emergency medicine physicians. A transcript and a curated (i.e. Storified) version of the tweetchat are available from the NephJC website. A summary is also posted on the eAJKD blog. The highlights of the tweetchat were:

• The investigators and the funding agency (AHRQ) should be commended for designing and funding this pragmatic trial to answer a key diagnostic question

• There was broad agreement about the validity of the results, suggesting that an ultrasound should be performed first in case of suspected kidney stones; however, many participants look forward to more data being published, on patient characteristics that predicted subsequent CT scan use and details of the economic analysis

• A concern was raised about the availability of point-of-care ultrasound in emergency departments, and the expertise and/or experience necessary to do these. It was recognized that this expertise is indeed rapidly becoming the standard for emergency room physicians

Interested individuals can track and join in the conversation by following @NephJC or #NephJC, or visit the webpage at NephJC.com.

On 2014 Sep 30, Ryan Radecki commented:

Post-publication commentary:

"Farewell, CT Stone Protocol"

Ureterolthiasis has become a poster child for over-utilization of advanced imaging. Despite the relative level of distress kidney stones cause our patients, the use of computed tomography has never been associated with improved outcomes – yet, CT is widespread for its diagnostic utility, contributing substantially to $2 billion in annual healthcare expenditures for this condition in the U.S. alone.

This, however, is a comparative effectiveness evaluation promoting ultrasound for the diagnosis of ureterolithiasis in the Emergency Department, a three-pronged evaluation comparing CT, formal ultrasonography by radiology technicians, and bedside Emergency Department ultrasonography. Essentially, the objective of this study was to compare safety – regarding, in a sense, whether the additional information supplied by CT was valuable for the detection of life-threatening alternative diagnoses. And, with respect to this outcome all strategies had, essentially, the same number of “misses” during the follow-up period – mostly acute cholecystitis, one case of appendicitis, and a smattering of other thoracoabdominal diagnoses. And so – ultrasonography, even our amateur sort in the ED, is "just as good"....

http://www.emlitofnote.com/2014/09/farewell-ct-stone-protocol.html

On 2014 Sep 30, Ryan Radecki commented:

Post-publication commentary:

"Farewell, CT Stone Protocol"

Ureterolthiasis has become a poster child for over-utilization of advanced imaging. Despite the relative level of distress kidney stones cause our patients, the use of computed tomography has never been associated with improved outcomes – yet, CT is widespread for its diagnostic utility, contributing substantially to $2 billion in annual healthcare expenditures for this condition in the U.S. alone.

This, however, is a comparative effectiveness evaluation promoting ultrasound for the diagnosis of ureterolithiasis in the Emergency Department, a three-pronged evaluation comparing CT, formal ultrasonography by radiology technicians, and bedside Emergency Department ultrasonography. Essentially, the objective of this study was to compare safety – regarding, in a sense, whether the additional information supplied by CT was valuable for the detection of life-threatening alternative diagnoses. And, with respect to this outcome all strategies had, essentially, the same number of “misses” during the follow-up period – mostly acute cholecystitis, one case of appendicitis, and a smattering of other thoracoabdominal diagnoses. And so – ultrasonography, even our amateur sort in the ED, is "just as good"....

http://www.emlitofnote.com/2014/09/farewell-ct-stone-protocol.html

On 2014 Nov 02, Swapnil Hiremath commented:

This study was discussed on Oct 7th 2014 in the open online nephrology journal club, #NephJC, on twitter. Introductory comments are available at the NephJC website and cross-posted at the eAJKD blog. It was a great discussion, with more than 20 participants, including nephrologists, urologists and emergency medicine physicians. A transcript and a curated (i.e. Storified) version of the tweetchat are available from the NephJC website. A summary is also posted on the eAJKD blog. The highlights of the tweetchat were:

• The investigators and the funding agency (AHRQ) should be commended for designing and funding this pragmatic trial to answer a key diagnostic question

• There was broad agreement about the validity of the results, suggesting that an ultrasound should be performed first in case of suspected kidney stones; however, many participants look forward to more data being published, on patient characteristics that predicted subsequent CT scan use and details of the economic analysis

• A concern was raised about the availability of point-of-care ultrasound in emergency departments, and the expertise and/or experience necessary to do these. It was recognized that this expertise is indeed rapidly becoming the standard for emergency room physicians

Interested individuals can track and join in the conversation by following @NephJC or #NephJC, or visit the webpage at NephJC.com.

On 2015 Mar 24, Michelle Lin commented:

Video interview with first author, Dr. Rebecca Smith-Bindman (UCSF Department of Radiology), and co-author Dr. Ralph Wang (UCSF Department of Emergency Medicine) hosted at the Academic Life in Emergency Medicine website. In this video, questions and nuances in this landmark paper were addressed.

http://www.aliem.com/author-insight-ultrasonography-versus-ct-for-suspected-nephrolithiasis-nejm/

Four questions were posed:

• Q1: About 1/3 of patients in the ultrasound study arms eventually went on to get CT’s in the same ED stay. What would you recommend to clinicians about when that should be?

• Q2: Can you address generalizability issues in this 15-center study whereby the cohort has 40% with a history of previous kidney stones and only 60% demonstrating microscopic hematuria. Also what are your recommendations for obese patients (men >280 lb, women >250 lb) who were excluded from your study? CT them all?

• Q3: What has been the feedback from urologists since the paper was published? What are the drivers of CT ordering?

• Q4: What’s next? What’s NOT in your paper?

Ultimately, this paper advocates for bedside ultrasonography over CT as the first-line diagnostic modality for patients with suspected kidney stones. In this 15-center study, the ~1800 ultrasounded patients had good primary and secondary outcomes despite the fact that 2/3 did NOT undergo a CT in the first ED visit.